Inside Anxiety

Don't Miss This

Anxiety is the most common mental health problem among adults, but it often goes undiagnosed and untreated. Find out why and learn how to get the help you may need.

We’re joined by Dr. Reid Wilson, a licensed psychologist and director of the Anxiety Disorders Treatment Program in Chapel Hill and Durham, North Carolina. He’s author of the book, “Don’t Panic: Taking Control of Anxiety Attacks.”

As always, our expert guests answer questions from the audience.

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Anxiety is the most common mental health problem among adults, but often it goes undiagnosed and untreated. Tonight you'll find out why and learn how to get the help you may need.

I'm very pleased to introduce tonight Dr. Reid Wilson, a licensed psychologist and director of the Anxiety Disorders Treatment Program in Chapel Hill and Durham, North Carolina. He is author of the terrific book, "Don't Panic: Taking Control of Anxiety Attacks."

Dr. Reid Wilson, welcome to HealthTalk Live.

Dr. Reid Wilson:
Thank you, Judy.

Judy:
Can I call you Reid?

Dr. Wilson:
You can.

Judy:
That would be terrific. Okay, I am embarrassed to say this on air, but I'll do it anyway. I have read and re-read your book many times, and I even take it with me on vacations, just in case I get anxious. It always calms me down. It's kind of like my bible. Tell us why you wrote this book. For people like me? And it's been out for what, 11 years now? Or longer than that?

Dr. Wilson:
Well, the second edition has been out 11 years. I first wrote it, actually it took me three years, 1983 through '85, and came out in 1986. My specialty was really in chronic pain, not in anxiety so much, and the media began talking about what we used to call agoraphobia which was really panic disorder. And people just started coming through my door like they were for all the other psychologists in the country and yet I had a kind of leg up because, working with chronic pain patients, I knew relaxation and hypnosis and some of the other calming techniques. And so I began to look at the literature to see how to learn more about it, and there was so very little information about how to treat people that that peaked my interest in doing research in what was there. And that ended up turning into the book "Don't Panic".

Judy:
Yeah. So let's start with the actual, real basics. What is a panic attack? And is that the same thing as panic disorder? And is all that the same as an anxiety attack and anxiety disorder? Parse this a bit for us.

Dr. Wilson:
Sure. Well a panic attack is the same thing as an anxiety attack. They're just synonymous, although people don't necessarily think that that's true. And if we look at the critical definition, we call it, "an onrush of uncomfortable physical sensations" plus what we call "thoughts of impending doom." So the physical sensations are going to be very much like that fight or flight response except exaggerated. So we're light headed, dizzy and my legs turn to jelly, sweating. You don't have to have all of these, but the set of them - racing heart, tachycardia, sense that you might faint or in some, we get into the thoughts of impending doom. These can either be, "I'm going to die or faint or humiliate myself in public," not necessarily in that order. Anything that would give me a sense that I am losing control of my body or my mind. So when you combine both of those, you end up having a panic attack. Some people will have the physical symptoms but can explain it to themselves or explain it to themselves within two or three seconds, and that's why they end up not having panic attacks.

If you have at least one panic attack in a month and then begin to fear having another one, then you have the possibility of being diagnosed with panic disorder. And panic disorder if in its extreme form, which means people will severely restrict their lifestyle. They'll stop driving or they can't be alone, they have difficulty going outside of their house. Then we call that panic disorder with agoraphobia. All of that falls under the umbrella of anxiety disorders. And there are seven different anxiety disorders someone could have.

Judy:
Since you mentioned agoraphobia a couple of times, how does that exactly relate to panic disorder? I mean if panic disorder gets so bad that you can't go out into the marketplace metaphorically - the rest of the world - that becomes agoraphobia and is kind of like extreme panic disorder?

Dr. Wilson:
It's like that. It's really the extreme avoidance is more the definition. It's how you respond to the panic attack. It's not that you have more severe panic attacks. You feel more incapacitated by them. And lots of times when we are not sure how we're going to perform, we will worry in order to get in control. And so we'll worry to try to solve the problem. And if worry doesn't work, then we tend to just avoid the situation altogether. And so when you choose avoidance, avoidance, avoidance and start avoiding in significant ways like no longer being willing to drive, no longer being willing to be alone, then that is agoraphobia. When I was working in Boston, I helped a self help group for a while, and there was a woman there who had had agoraphobia for 50 years, but she had not had a panic attack in a quarter of a century. She had not had any panic attacks in 25 years, but she never was alone, whether she was in her house or outside of her house. She never left a three mile radius of her home. She never saw the end of a movie because she had to get out of a movie theater before the crowd would leave. On and on and on she worshipped comfort, and if you're going to worship comfort, you're going to lose in this game.

Judy:
Interesting. Well, I mean, you've kind of described clinically what a panic attack is like, but what does it feel like to people? And by the way have you ever had a panic attack?

Dr. Wilson:
Sure.

Judy:
Do you know where of you speak?

Dr. Wilson:
Most of us have had a panic attack. I've jumped out of a plane once. I did have the parachute on, but that certainly was my worst panic attack of my life.

Judy:
Well wait a minute. Is that really a panic attack? I mean, that is a truly dangerous situation. You're not making that up.

Dr. Wilson:
Doesn't matter. Doesn't matter. The panic attack is an onrush of physical sensations and thoughts of impending doom. I was thinking, "Oh my God, I am going to die." I'm falling out of the sky at 120 miles a minute or an hour for 45 seconds, and I am almost totally blind with anxiety and really thinking this is the end of my life. So in an emergency situation or a threatening or dangerous situation, you still have a panic attack. Panic attack has so much to do with that psychological point of view of "I'm losing control and something horrible is about to happen to me."

Judy:
But I still would think that panic is not as related to reality as you being about to jump out of a plane. I mean, when you were talking about this onrush of horrible feelings and feeling of doom, I immediately thought of all these soldiers in Iraq, and they must be having non stop panic attacks.

Dr. Wilson:
Well, absolutely. Again, any time you perceive it to be dangerous, you are vulnerable to having a panic attack. So you can be on a plane and be in the middle of turbulence, which of course is perfectly safe on a plane. These planes are built like battleships. They don't, they would hardly ever face turbulence that would be of any kind of threat to a plane, and yet if I perceive turbulence to be dangerous, that's my interpretation. And it doesn't matter whether it's safe or not. I can have a panic attack out of that fear for my life, or even real situations in the same way. Certainly people develop post-traumatic stress disorder from situations like Iraq and Afghanistan and the Vietnam War, and the panic attacks are based on quite real threats. One of my clients talked about it feeling, like going around the corner in a dark alley and having somebody put a .45 gun to your skull. Well that can certainly happen in reality too.

Judy:
But in some people, don't panic attacks feel like they come from- "out of the blue?" And you're standing in some completely safe place like the grocery line or you're at home or even some people get panic attacks in their sleep. Now that's not related to any external threat.

Dr. Wilson:
Absolutely. And in fact the average person with panic disorder has his or her panic attack out of the clear blue. And that's what is so startling. I'm sitting watching a television show or I'm standing in a line or I'm driving my car and suddenly I have this experience, and it's unexplainable and this is why so many people end up in the emergency room on their first panic attack or their cardiologist's office to find out. There's lots of research on the correlation between people having panic attacks and perceiving themselves to having a coronary emergency and having all kinds of tests that are taken. The average person with panic disorder sees 12 physicians in 10 years without even getting the appropriate diagnosis or much treatment. So that's because it gets misunderstood and misdiagnosed or under-diagnosed. You see your general practitioner, and they'll say you're just having anxiety and take this pill and it's nothing to worry about. Well that is under-diagnosing the problem or misdiagnosing the problem. So that's one of the things we want to settle very quickly with somebody with panic disorder. You can't tell the difference between a panic attack and a heart attack. You can't. For people who have those types of symptoms you have to go to a physician at some point ,and go through a workup to make sure there's no physical disorder. But once we've ruled out the physical, then you have to start treating it like psychological even though as you have a panic attack, you have pain shooting down your left arm and it feels just like a heart attack.

Judy:
You do? You really do have pain shooting down your left arm?

Dr. Wilson:
You certainly can have pain shooting down your left arm from the panic attack.

Judy:
Well, go back to the people who do get these panic attacks out of the blue. I mean, they're sitting there, minding their own business, and suddenly they get a panic attack. What causes those panic attacks?

Dr. Wilson:
Well, there's a very strong genetic component in panic disorder, and if we talk about some of the other anxiety disorders, they actually have a stronger genetic component. There are developmental issues, childhood issues that sometimes come into play about people with panic disorder. Something close to 70 to 78% of the way we account for a panic disorder is having a family history of panic disorder.

Judy:
Yeah, I've read that.

Dr. Wilson:
There's a strong disposition. You can have people who might develop some anger management problems or alcohol problems from particular stressors in life that are similar people with panic disorder, but the genetic component pushes these people to panic attacks as opposed to depression, alcoholism, violence and so forth.

Judy:
So they're the lucky ones or what?

Dr. Wilson:
Well, we have that combination, but the other thing that we often see is about six to eight months of stress prior to the first panic attack. And that stress very often has to do with loss. So "I've lost my job" or "we've moved" or a friend has died or "I've gotten divorced" or "I've gotten married and that's a loss," or "I've become pregnant and that's a loss of my freedom."

Judy:
Why are marriage and pregnancy losses?

Dr. Wilson:
Well, you lose certain amount of freedom when you get married. You are trapped in a relationship that you've just bound yourself to. When you're pregnant, some people feel somewhat insecure…

Judy:
I said you've lost even more freedom.

Dr. Wilson:
Well yeah, there you are all of the sudden having to think about taking care of somebody else when to some degree, you're not quite sure you're ready to mature into life and completely take care of yourself. So there's a plurality of people with panic disorder who had what we call "early childhood loss." So a death in the family or of a parent or long term illness of a parent or a parent going off to war - those types of things. And families of people with panic disorder as well as families of people with simple phobias, specific phobias, tend to be families who do not process conflict or loss. And with that being unresolved, grow that person up and suddenly they're experiencing a new loss in a similar vein. Up pops the panic attack totally unrelated to that event. So it's coming out of the clear blue, so nobody makes the association. "Oh my husband left me three months ago. This panic attack must be about that," so they miss that piece and the messenger. To some degree, panic attacks for some people is or are messengers of something they need to look at in their life, but the messenger is so ugly that they get distracted by the messenger and miss the message. So sometimes I talk about the benevolent purpose of the symptoms. We want to make sure that if there is some message there that it's bringing us, that we catch on to it, and if we do, sometimes that intensity and strength of the symptoms begin to subside.

Judy:
And by the way we should mention that this incredibly common. I think it's more than 2.4 million Americans have panic disorder or have panic attacks. Is that roughly right?

Dr. Wilson:
That's right. And there are maybe 7 million people who have simple phobias. But far more people with panic disorder come into treatment than people with phobias because…

Judy:
Because you can avoid the phobic thing.

Dr. Wilson:
…you can avoid them. And so with panic attack, it becomes much more debilitating for people. The good news is this is probably the most treatable mental health disorder that we have. Not just anxiety disorder. So 90 percent of the people who get the appropriate treatment get better 90 percent. Once we get it diagnosed properly and get them with the right person, they do pretty darn well and self help works great. Researchers in Canada are doing a lot more research on the use of self help for panic disorder and other disorders because of socialized medicine there. Some studies are showing self help can be almost equal to sitting down with a therapist every week.

Judy:
Well, since you've mentioned it, what is self help for panic disorders? What do you do? How do you help yourself?

Dr. Wilson:
Well, really all the treatment is self help. We teach people strategies. Most of the work doesn't take place in the session with the specialist, it takes place outside of the session. And there's really two major ways that we work with people. The way we used to work with people predominantly, almost totally, was what I would call the permissive approach. Meaning you permit the symptoms to exist and this sounds crazy at the beginning because we're not saying, "Oh you simply have to tolerate your symptoms because you've got this chronic illness and you have to put up with it." It's like diabetes or, you know, Type I Diabetes. No, we're talking about as a strategy. Because the way you respond to a panic attack is you fight it and what we know clearly is what you say about a panic attack in a positive way is almost completely irrelevant.

What we're trying to focus on with people changing their thoughts is not so much having supportive statements that help me but not resisting the symptoms. And so permissive, that's where we start teaching breathing and relaxation skills and so forth. So there's this whole aspect of the treatment that is permissive by nature and then where we're really going today, which is becoming more of the cutting edge work is the provocative work which I know you're familiar with to some degree, but most people have no idea what we're talking about. But we're talking about provocative treatment we're talking about my objective is to provoke the symptoms that I am fighting. We're going to do exactly opposite of what logic tells me to do.

Judy:
Well, since you've brought it up and we talked before the show, that's how you know about my little thing. I sing in a classical music group and have for many, many years, and one of my worst fears has always been that I'll faint during a concert. And a few years ago I did faint. It turned out I was coming down with something because I had a fever and whole bunch of other symptoms the next day, but we were singing, and I really started feeling queasy, and I thought, "I'm going to faint. I gotta get out of here." And we were all packed in too tightly together to get out, but I really thought, "I've gotta get out of here. I'm going to throw up on people." And as I started to move, I fainted. They had to stop the entire concert. I mean, this was literally one of my worst, nightmares and did leave me with an even greater fear of fainting during concerts. I went to a person who sounds a lot like you in Boston, and the basic teaching there, which I have to say was difficult, was basically try to bring on the panic attack. You know, they'd make me spin around till I got dizzy. They'd make me – I don't know – hold my breath or something.

Dr. Wilson:
We are sadistic, Judy.

Judy:
You are sadistic. I have a concert on Saturday, we'll see. But now I don't really feel as anxious about that as I used to. But it's a strange thing to go through.

Dr. Wilson:
Right, but we're talking about people's medical problems, and so what in the world do you do with someone who is actually had a myocardial infarction and has panic disorder at the same time? We work with these people all the time. We work with people with COPD [chronic obstructive pulmonary disease], who have breathing troubles. Working with people who've actually blacked out while they're driving and want to start driving again but have had panic attacks. So your experience is very similar. Okay, well I'm afraid of fainting but that's real. Often you'll get people who are afraid of throwing up or vomiting in public and you'll be a thirty-five year old person, you'll say, "When's the last time you threw up?" And they'll say, "Well, six years old." So, you know, there you have somebody with a real phobia without much data. But here we've got data. I really can faint. Well, one of the most important issues that you have to address is, if it occurs, how will I cope? And you want to be absolutely as concrete as possible. Listen to this, you want to be concrete about how it will happen because then you want to be very concrete about how you'll cope with it. What we find is people have the most trouble with these types of fears when they're vague about how it's going to occur and therefore vague about how they're going to respond.

Judy:
Well once you've fainted in front of an audience full of people and you've wrecked your group's entire concert and they stop the whole thing, there's not a lot of coping going on. You're unconscious in the front row, having mowed down the people in front of you. I mean, what kind of coping can you do once you're unconscious?

Dr. Wilson:
Well, that's not what we're saying. We're saying, if I were to faint, two things: one, is if I were having a kind of aura that I was going to faint next time, how would I respond then instead of waiting and going ahead and fainting? Number two, if I do faint, how will I cope with the fact that I fainted and stopped a concert and have been taken off stage and the emergency squad has been called? You still have to have a way that you will cope with that. And I do recommend if when your therapist worked with you on this that if they didn't do that work with you, that's still work that you need to do, which is okay. If I can tolerate the symptoms, and if it happens here's how I'll cope: I'll be embarrassed, I'll apologize to people and I assume life has gone on from this last episode and it will again. And if you've got somebody' with myocardial infarction, so I've had a heart attack, what we're going to do is talk to your cardiologist and we're going to set up a criteria for what set of symptoms makes it automatic that I call 9-1-1. You know, what if this is a heart attack or not if you have the symptom of an elephant on your chest and difficulty breathing. Whatever that list is, regardless of whether it's real or not, you call 9-1-1. If it doesn't meet those criteria, you are to treat it as a panic disorder.

Judy:
So you specify very clearly for the person exactly when to call 9-1-1.

Dr. Wilson:
Right. You make a rule. You make a set of rules and because otherwise this is the trouble with panic disorder and so many other anxiety disorders. People want 100 percent guarantee that something is going to not occur, that they won't have trouble. That these skills, you know, we're going to teach people how to tolerate how to prevent. How to stop a panic attack once it's begun. But we're always going to start with how to tolerate symptoms. Not how to stop symptoms because everybody's seeking to stop the symptoms, and that's how they pump more adrenaline through their body and create the symptoms they're trying to stop. So this is, paradoxically, absolutely opposite of logic. You know, I worked with a woman who has social anxiety and is a blusher. So her face turns red very easily and her neck gets splotchy. She wears a turtle neck 365 days of the year because she doesn't want anyone to see her neck red, and she came into treatment wanting to get married in nine months and walk down the aisle without blushing. Well, that goal can never be met if she keeps that goal. That sounds crazy, doesn't it? But she has to be willing to walk down the aisle and be blushing in order to learn how to walk down the aisle without blushing.

Judy:
Well, flesh that out a little bit. I mean, that seems like a good example. So you sort of have to, her job in your therapy would be to tell herself over and over again and tell her husband to be and everybody else that she's going to blush when she walks down the aisle. She'll hate it. But she's trying not to hate it but it's going to happen and so be it?

Dr. Wilson:
Almost. You know, first of course we're going to start with these low-grade situations wherein she's in graduate school. We're going to get her to start going to situations without wearing her turtleneck and tolerate that. We're going to have her put herself in situations where she literally does blush and tolerate that. And again, paradoxically the way I'm working with people today – have I mentioned these things sound crazy – is that I train her to hope that she blushes to beg panic or social anxiety to cause the blushing, to imagine she's going to get 25,000 dollars magically placed in her checking account if she can get her neck to turn bright red with large blotches as she walks down the aisle. That is the best way to overcome the disorder.

Judy:
You didn't tell her to get a turtleneck wedding dress?

Dr. Wilson:
No, absolutely not. No. But it took literally nine months to get her to wrap her mind around the idea that, "if I stand in the back of the church and say, 'Oh, boy I sure hope these techniques are going to work because if I blush this will ruin the most important day of my life.'" That message standing in the back of the church is the absolutely worst message she could possible give herself, and it would guarantee her blushing.

Judy:
We have a question on this very issue from Jody in Kansas. And she writes, "When I hear people talk about anxiety, they always mention sweating, breathlessness and a racing heart. I'm a very anxious person, but I rarely have any of these symptoms. My main symptom is blushing. I do it in any and every situation, and it's humiliating. What can I do to stop this?"

Dr. Wilson:
So we've kind of started on this track, and hopefully we'll talk more about this whole idea. This is a mental game, and panic disorder is looking for your vulnerabilities and will take advantage of it. And so you have to use finesse. And in this game you want to operate opposite of what panic wants you to think. And so when panic throws you a situation that is important to and pitches a sense that your face is starting to turn red and anxiety about that response. When you go, "Oh, no, this is terrible, I can't have this happen once again." That's what panic needs in order to win, and you will guarantee yourself that experience. So early on in treatment or in your self help work, you're actually going to have to put yourself into situations where you blush, and if you can start, the position you want to take is, "I want to get over this badly enough that I'm willing to tolerate blushing." And then you go after that with tenacity, panic disorder, or in this situation probably social anxiety, by trying to make it happen. Hoping it happens. Literally having it occur. Learning that what we were talking about earlier about your fainting, learning that I can cope with it and figuring out what the coping mechanisms are. The prediction that we have around a threatening situation is how soon it's going to happen? How likely is it going happen? How bad is it going to be? Divided by, how well can I cope? Well, the thing about how bad they're going to be is really directly related to the degree I think I can cope. So that's in a short way of describing it for Jody. That's where we're going to go, which is go toward it, experience it, and get used to it and then say, "Look if it happens…" - in the end it's a kind of permissive statement - if this happens it's okay with me. In the beginning I encourage her to go, "if this happens, it's exactly what I want. I am seeking this experience."

Judy:
I am so happy I am blushing in front of all these people?

Dr. Wilson:
Really. Here's what we know from the research, Judy. The research to create habituation - and habituation means forming a habit of exposure to the feared situation significantly enough that I'm not so threatened by it - and if you want to, therefore, habituate to an elevator or an airplane, water or whatever it is, you need three things: frequency, intensity, duration. You have to expose yourself to that threatening situation often enough. You have to get on a scale of zero to a hundred of anxiety, you need to get up to about 50 in your anxiety as you face that. And you need to do it for about 45 minutes to 90 minutes every time you practice. That's what we call habituation: frequency, intensity, duration. You need to go toward that experience to get better in behavioral therapy. What we're talking about here is what we would call a cognitive therapy which is, we're going to take a little shift in all of that to say, "I want to have the symptoms. I want to…"

Judy:
That's not a little shift. That's a huge shift.

Dr. Wilson:
Well, it is a huge shift, but we're adding a piece, yes. But if, God forbid, someone who's listening has to go through chemotherapy or radiation for cancer, it's a terribly painful experience. You get physically ill and nauseous, exhausted and so forth and when you are driving to the hospital, you darn well better be saying, "Thank God I live in the 21st century. Thank God there is chemotherapy and radiation to augment my body's ability to heal itself." Because that attitude is placebo, and placebo is 30 percent of your ability to heal yourself. So you want to have that positive approach about the treatment. Well, how do we approach threatening situations when we're trying to practice these skills with anxiety, "Oh, no I've got to go to the party and, you know, introduce myself to people and get all embarrassed? I hate this, but I know I've got to do it." That's the attitude that I'm saying we have to switch. If you need to go to the party and expose yourself to other people's criticism in order to get stronger then I'm saying you should also want to do that. That's on two levels, wanting to do it is taking control of it and owning the work like you're the subject process instead of the object and second is it is exactly opposite of what panic needs you to say.

Judy:
We have a couple of e-mail questions that have come in now. This one is from Claudia, and I'm sure she speaks for many people who are listening when she writes, "I solve my anxiety with food. Now I'm depressed because my weight went from 160 to 230. How do I learn to manage my anxiety without using food?"

Dr. Wilson:
Well, you're right, it's not that uncommon of a situation. People get stressed out and begin to look for what we've all now called comfort foods to reassure us. And, you know, part of what we might say is that food, like so many other ways that we cope with our problems, is a defense. It pushes us away, and we know in treating people with panic disorder and other anxiety disorders that we want to have people look at their problem in such a way as to go forward towards it instead of away from it. So part of what we want to do is find out, "Well what is it that I'm trying to avoid?" And instead of working like, "Oh, let me control my food." Let's go in the direction of if I can figure out how to solve this problem I'm trying to run away from, then I won't have to then rely on the food. And again, we get back to what you and I have been alluding to which is, "I need to know that it's possible that I have the skills enough to handle this challenge in front of me or I know where to get the support to develop the skills, and I know how to cope with the problems that come forward." I'm obviously having to be very general because she's not telling us specifically what's she's avoiding.

Judy:
Well, let's picture her as every woman, and it's 11 o'clock in the evening, and she's feeling anxious, and she's sort of tempted to go to the refrigerator and get some ice cream or cookies or whatever. What does she say to herself to stop that behavior? I mean specifically what would her - I mean not her specifically, if you don't want to talk about her - but a person in that situation, what are they likely to be thinking? And what would you have them change their thinking to be, so that they didn't gorge on ice cream or whatever?

Dr. Wilson:
Yes. Well, I can respond to what you're asking, but I need to back this up for a minute because you're asking me to help her figure out how to respond in that moment to the desire to eat because of anxiety. And that's a difficult way to solve the problem. Which is, at this moment of craving, if as I'm saying it, we need to back up a little bit and look during daylight hours as to what is going on that's causing me to develop this kind of anxiety, so that I begin to attack the actual source of the anxiety. I might be lying down at bed at night and beginning to worry about how my work is going to go tomorrow, and I don't want to think about that anymore. I need to get to sleep. I'm going to have insomnia unless I start filling up my belly and quieting myself down. So, first off, I'm just saying that you need to back up and really identify what those problems are. And address those head on. That cannot be diminished. Let's assume that we're doing that as well. Now I have a moment within in which I'm noticing myself getting really anxious and wanting to eat, and there are a number of things that we can do. We would want to teach a lot of people how to do relaxation skills in some ways because how can I turn my body's adrenaline system down? And we know pretty darn well that using yoga, using meditation, using simple breathing skills in the moment, learning what we call cue controlled deep muscle relaxation or other relaxation methods…

Judy:
Wait what is cue controlled methods?

Dr. Wilson:
Cue controlled deep muscle relaxation – it's about a 20 minute exercise that you listen to on a tape. That is a kind of relaxation exercise, but it has cue on it, which is how you breathe. You develop a cue word like calm or relax every time exhale and it's how you feel at the end of that tape when you're feeling more relaxed, and that gets memorized by the brain. If we have someone do it twice a day for one week and once a day for four weeks, and it takes about five weeks according to the research for us to develop neuropathways in the brain to respond to those kinds of cues. Then I can take a simple deep, full breath and a nice slow exhale, say that cue word and invite my body to respond to that cue word like "calm" or "relax," and all that experience of learning formal relaxation comes rushing back into my mind. And in a matter of 30 seconds, I can begin to quiet and calm myself down. Now, we might say that is a more of a passive way to quiet myself. Perhaps if I'm really feeling hungry, I need to do something a little more active. I need to phone someone else who's still up at 11 o'clock or I need to pull out my diary and start writing down all the feelings that I'm feeling that are making me want to eat or I need to go drink a eight ounce glass of water instead of food. So we could make a full list of interventions at that moment, but we have to, number one declare, "I want to have an alternative other than my food. I have to develop an alternative that actually works for me."

Judy:
Sorry, didn't mean to stop you. We're getting some great e-mail questions tonight. I wanted to move on to a couple more. Tim in New Mexico writes, "My anxiety problems are killing me. I do not want to take any more drugs. The drugs only intensify the problem. My feeling is it's only putting a bandage on a wound." He doesn't say what drugs he's taking, but in general, talk about medication treatment for anxiety and when it's appropriate and when it's not.

Dr. Wilson:
And do you want me to speak of anxiety as a whole or panic disorder?

Judy:
How about both.

Dr. Wilson:
Sure. It's a little easier to talk about panic disorder because it's a very specific one and once we get to others, then it's a little broader. But thirdly, medications can have a place for people with panic disorder. I think people's need for medication and its usefulness runs the continuum from unnecessary to thank goodness medications are here. The predominant medication that we use today is what we call SSRI's. "Selective serotonin reuptake inhibitors" and this means there is a neurotransmitter in the brain that we believe is related, probably several neurotransmitters, but the one these medications focus on is not dopamine but is serotonin.. So we're finding that people, that in the neuroreceptors sites as they provide the serotonin, it gets taken back up from the cell that just gave it over, and so that's what we're talking about re-uptake inhibitors. Those medications prevent that neurotransmitter from getting sucked back out, away from where it needs to go.

Judy:
The net effect being more serotonin in the brain.

Dr. Wilson:
More serotonin. The serotonin is there and has been underutilized. So it allows it to be utilized more efficiently. Which we think makes a contribution to helping people control panic attacks.

Judy:
And many people think of these drugs as anti-depressants, which they certainly are, but you're pointing out a well-known fact that they also work for anxiety.

Dr. Wilson:
Yes. Almost all these anti-depressants except for Wellbutrin work for anti-anxiety. Most of them were initially approved by the FDA for depression. Several of them have been approved now for panic disorder as well and of course any medication that has been approved can be used for what we call off-label uses like panic disorder even though it's only been approved for depression. These are called systemic medications which means you actually have to take them for a number of weeks before their benefits can be even felt.

Judy:
Well, what about Tim's and other people's philosophical dilemma? They want to feel better, but they don't want to take the drugs. What do they do? Because I think some people feel shame about taking drugs, but other people really need. Can you take these drugs for a short amount of time and then move on to the cognitive behavioral treatments? Or what do you recommend in general?

Dr. Wilson:
Sure. Well, I'm sure that Tim's response, his philosophy comes out of his experience, which is that he's had really a lot of trouble with the medications. The side effects have been tough for him, and side effects can be hard for people. There are sexual side effects, and sometimes there's weight gain and some other side effects that can be surprising and overwhelming to people. And a number of people with panic disorder, particularly, are sensitive to medications. They don't like to put anything in their body because they don't like their body to feel funny. If someone were walking into my office with a prescription and coming into treatment for the first time and haven't filled their prescription, I would ask them and their physician if they would be willing to hold that prescription for four weeks. And let's get four sessions under our belt of teaching them self-help skills and see how well and how far they can get before they take a medication. And because when you take like the one we've just talked about, you're going to be on there minimally six months if not one year. And one of the problems with medications with people's panic disorder is many of these people have a lower sense of their self-esteem and with lower self-esteem, you attribute positive things in your life to external agents and the negative things to yourself. So we might be working along very well and they're applying great self-help skills and also taking a medication, and they'll completely attribute it to the medication and not the self help work.

Judy:
If they feel better. Yeah.

Dr. Wilson:
That they feel better. So that's another issue. And half the people I see are already on medications when they come to see me, and so there we are but my population is skewed. That means that these people have come because the medication hasn't worked for them and they need help, and there's certainly a lot of people out there in the world who've tried medication, and it has helped. We know from the research that cognitive behavioral therapy works very well in many cases even better than medications. It, medications, may have a jump on cognitive behavioral therapy early on and take a better effect, but it loses the race over time. And the biggest drawback with the medications is that when you decelerate from the medications a great percentage of people will rebound back to their original spot, and they haven't learned anything. If they haven't learned anything, then the medication has just been covering up the problem instead of repairing the problem. And lots of people do medications and cognitive behavioral therapy. If you leave my practice and are doing really well and still on the medication and you decide months or years later you want to get pregnant or for some other reason get off the medications, we recommend that you come back into treatment and have what we call cognitive behavioral therapy because the brain operates in context, and even if you're doing well when you start decelerating from a medication, the brain says, "This is a new context, I don't know what this is like." And very often people will start to have more trouble with their panic, and we like to go and kind of refresh skills and get them on board so that they can tolerate some of the symptoms. Otherwise they start going, "Oh, I still have panic disorder, I still need to be on this medication the rest of my life." And there they are trapped.

Judy:
Yeah. That makes a lot of sense. We've got another question from Cynthia in Florida. She writes, "When I have to speak before a group, my voice changes, and I have been known to actually experience shaking legs to the point that my feet raise up off the ground from the fear of talking. Besides just talking more and more in public to learn to put up with it, is there anything else I can do?" And this again is a really common problem. Fear of public speaking.

Dr. Wilson:
Sure. I'm imagining her rising up off the stage. It just seems like that would impress the entire audience at that moment. She'd have them…

Judy:
Levitating.

Dr. Wilson:
Yes. Not quite sure how that is, how she's experiencing it, but certainly the shaky legs are common. Shaky hands is worse of course because you're imagining people can see your hands shake, and that is horrible. And Cynthia, again, brings up a very important point. I'll have people that come to see me and say, "Look, I go grocery shopping every week. You know, going out there and doing it doesn't seem to be helping me much." And that's exactly true. The protocol of what we call "exposure" - where you go and face your feared situation - exposure itself is insufficient. It needs to be exposure plus, "How am I thinking about what's happening at this moment?" And that's where we get back the, "What's going to be my disposition?" If I can learn to tolerate having people see my legs shake or my voice quiver and accept that and speak anyway, then I'm going to get stronger. Very often, for people with a public speaking fear, it's the first two or three minutes where they have trouble. You know, if I can learn some tricks like throwing a slide up on the screen and have people look at the slide while I'm talking, to take people's attention off my face and let me kind of collect myself, that's one of the tricks we'll do. Or give out a handout and ask people to look down at their handout for a minute as they begin. So there are little things that we can do to get us through that hump at the very beginning, and that's why we like to send people, when they're able, to groups like Toastmasters. Toastmasters is really a laboratory. There are Toastmasters groups all over the world that train people in a very supportive environment, for about an hour every week or every other week, the skills of public speaking where you can practice getting up with quivery legs or quivery voice and pushing through that. So with Cynthia, she needs to not only do the exposure but have a particular attitude as she's practicing.

Judy:
What about when the anxiety comes from an actual medical condition like maybe hyperthyroidism or something? Does that change how you would treat the anxiety?

Dr. Wilson:
Well, the anxiety comes from medical conditions, the biggest problem with that is people not realizing that it comes from the medical condition. The condition that is most likely to cause symptoms similar to panic, for instance, is mitral valve prolapse in the heart and, it can bring pain to the chest and tension and some skipped heart beats, and so forth, and if I misinterpret it as something dangerous there, I am going to have trouble. So, chapter three of "Don't Panic" talks about all the physical disorders and side effects of medications that mimic some aspects of a panic attack. Like difficulty breathing and heart troubles and shaking and so forth. So the recognition of the physical disorder is critical and then being able to explain the response I'm having. But there is no difference whatsoever from somebody who has a spontaneous panic attack out of the clear blue or someone who has a panic attack because they have mitral valve prolapse or some other physical disorder if they interpret it as dangerous. Probably 50 percent of people with mitral valve prolapse get those kinds of symptoms. But only 15 percent of them develop panic attacks from that. and that has to do with interpretation.

Judy:
How people interpret for themselves?

Dr. Wilson:
Yeah. Same thing I just saw a young man the other day who said, "Look, I was smoking marijuana three weeks ago and had this panic attack, and now I'm, terrified, and does marijuana cause panic disorder?" No. Marijuana creates an opportunity. You're a panic disorder waiting to happen, and marijuana can produce symptoms in such a way that you react with a panic attack and then attribute it to the drug. For years people were treating panic disorder as though it was hypoglycemia because they would go to a grocery store and have a panic attack and think it was somehow related to not eating. And so when you misinterpret it, misdiagnose it, you then mistreat it.

Judy:
We got a follow-up e-mail from Cynthia who was concerned about public speaking, and she just wanted to make sure we understood. It's not that her whole feet come off the ground. She doesn't like levitate. It's just that her heels come off the ground, and she doesn't want people to think she's haunted when it's merely panic attacks. So thank you Cynthia. I wanted to go back to something that you mentioned earlier on in terms of the family history and the childhood experience of people. I think you were talking about families where people don't deal with conflict well or they don't acknowledge difficult emotions like sadness or anger. Does that kind of a family situation lead people to have panic attacks? In other words, do panic attacks come from people being afraid of their own emotions to some extent?

Dr. Wilson:
Well, they certainly can, but let me back up a little bit around the family history. You're going to see two types of parents very often in these families if the family does contribute in some way to panic disorder, and one is having a dominant or controlling parent. This is why sometimes we have adult children of alcoholics who also have panic disorder because that dominant, critical, controlling parent says basically, "You listen to me and follow what I say, and then you'll be okay." And that type of parent develops a child who has what we call external locus of control. I am more concerned with how Dad's doing, what's he look like when he comes through the door than I am of what I need and what I'm feeling. And so my ability to pay attention to my own emotions and my own needs kind of atrophies over time out of survival.

Or the second type of parent which is very common in people with panic disorder and other phobias is the overanxious parent. And of course, we've already said this runs in families. So if you've got a mother or a father who is presenting symptoms of anxiety - the average parent might say, "Don't climb up in that tree, you may fall down and break your arm" - these parents say, "Don't climb up in that tree you may fall down and break your neck." You know, "Don't go out in that creek you might drown. Don't go off with those boys you never know what might happen." So the message is the world is a dangerous place. "Listen to me and I will tell you how to act." So you hear the dominant, critical parent and the over-anxious protective parent give the exact same message to the child: you can't trust yourself. "Don't bother paying attention to what's going on for you and pay attention to us."

So when you grow this person up, one of the things that we find is over-dependence on other people. Fear of abandonment. "I don't think I'm lovable, I don't think I'm capable and am afraid of any kind of conflicts." Well, one reason they are afraid of conflicts is they don't want to be abandoned. The other reason is it's an intense emotion, and they shut their emotions off long ago. And so to be really angry, it's like falling into the abysmal pit. "I'm so unfamiliar with that feeling. Am I going to go crazy with that, or am I never going to be able to stop?" So that's where we start to get into people who have a fear of intense emotions, and very often they don't know that's going on. And so it takes a relatively savvy therapist even to be looking for that dynamic that might be causing people to avoid conflicts with others in the world. That goes hand in hand with even more significant one which is, especially agoraphobia, "I am so insecure and I am so unlovable that I have to keep people in my life, no matter what it costs me, even if it costs me my happiness."

Judy:
We're about to run out of time, but I'd like for you to just talk for one minute or so about your metaphor in your book which seems wonderful that kind of treat panic like a judo opponent or something that you sort of go toward it and you use the energy of the panic, and you sort of try to pull them in instead of fighting them off. Have I got that right?

Dr. Wilson:
Yes, and you do. And I think as we just mentioned at the end, it is what we've been saying all along. You know, the American way is put up your dukes and fight and anything that is resisted will persist. And in the martial arts it is, instead of push back when somebody pushes, you pull when pushed. So if somebody throws you a punch, you grab their arm. Use their energy and move them right on by you. And so that's what we want to use, the energy, and if you think back on these silly things that I've been saying like, "Boy, I am so looking forward to blushing when I go to that party tonight," or, "Oh please panic, give me a number ten panic attack. I'm so looking forward to it," of course, we're not serious that we are so excited about it. It is a caricature of "I'm willing to be anxious. I know I need to do it frequently. I know it needs to be intense enough. And I know it needs to last long enough in order for me to get over it. And so I'm going to take those principles and I'm going to run with those in a kind of cognitive to force myself not to resist." If you'll remember at the very beginning it's all about resisting…crazy things.

Judy:
You know, we could go on for several more hours, and I would love to, Dr. Reid Wilson author of "Don't Panic: Taking Control of Anxiety Attacks," but we are absolutely out of time. And Dr. Wilson, thank you so much.

Dr. Wilson:
Thank you for letting me talk with you.

Judy:
Thank you, and I'd like to thank you, the listeners, for joining us. Until next week, I'm Judy Foreman. Good night.

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